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Chapter 2The Pre-Travel Consultation

Perspectives: Prioritizing Care for the Resource-Limited Traveler

Ilan Youngster, Elizabeth D. Barnett

Travelers seen in pre-travel clinic consultations often have financial constraints. Prioritizing immunizations and prophylactic medications should be part of an individualized assessment based not only on the travel profile and efficacy and safety of vaccines and medications, but also on associated costs. Travelers must often pay out of pocket for pre-travel care, as many health insurance plans do not cover travel immunizations and prophylaxis. Travelers with limited budgets tend to be at higher risk for acquiring travel-associated infections, as they often visit remote areas, stay in lower-grade accommodations, and are more likely to eat local street food. As an example, the estimated cost of a pre-travel consultation for a young backpacker planning a 4-week trip in West Africa will run as high as $1,400 for the initial consult and vaccinations, excluding malaria chemoprophylaxis. Clinicians need to understand travelers’ financial constraints in order to provide realistic recommendations. Helping travelers with limited budgets decide how best to spend limited resources on travel vaccines and medications is one of the most challenging tasks of travel medicine specialists. The variety of insurance plans, number of travelers without adequate insurance coverage, and number of student and budget travelers vexes even the most savvy travel medicine clinics. This section provides guidance and strategies for prioritizing vaccine and medication choices for the busy practitioner.

VACCINES

Required Vaccines

Only 2 vaccines are categorically required for some travelers: meningococcal vaccine for pilgrims traveling to Mecca during the Hajj and yellow fever (see Chapter 3, Travel Vaccines & Malaria Information, by Country). If either of these is required for an itinerary, prioritize it since the traveler may be denied entry to the country without proof of vaccination.

Routine Vaccines

CDC recommends that all travelers should be up-to-date on routine vaccines before international travel, regardless of destination. Routine vaccines are generally associated with lower costs, as they are produced for mass administration as part of the scheduled national childhood and adult vaccination programs. The benefit of their administration extends beyond the travel period, and in many cases immunity for life is achieved. Moreover, many health insurance plans will reimburse the patient for the cost of their administration. If a traveler requires routine vaccines and cost is a limitation, he or she can explore opportunities for obtaining them in a health department or primary care setting, where cost may be lower than in a travel clinic. Prioritize the routine vaccines that protect against diseases for which the traveler is most likely to be at general risk. At this time, top priorities would be influenza vaccine and measles-containing vaccine.

Recommended Vaccines

The patient may have prior immunity to the disease for which immunization is being considered. In some settings, testing for antibody concentrations may be covered by insurance, while vaccines are not. Specifically, hepatitis A and B are vaccines important for travelers’ health and should be considered for susceptible hosts. Testing for immunity to these infections may determine whether vaccination is warranted.

In recommending vaccines, a provider should consider the destination, the expected itinerary, seasonality, and baseline risk factors in the patient. Review the itinerary to determine the need for specific vaccines based on destination or purpose of travel: polio vaccine for travel to endemic countries, meningococcal vaccine for travel to the meningitis belt of sub-Saharan Africa or to an area where an outbreak is occurring, or hepatitis B vaccine for travelers likely to have blood and body fluid exposure (health care or humanitarian workers, for example).

Consider travel vaccines based on time until departure, risk at destination, effectiveness of vaccine, and likelihood of repeat travel. Hepatitis A vaccine will frequently be a good choice given the high efficacy, duration of immunity, and prevalence of risk. Parenteral typhoid vaccine may be less cost-effective for infrequent travelers (especially when departures are imminent and trip duration is short) because of the low efficacy, short duration of protection, and time needed for onset of effectiveness.

Educate about alternative ways to reduce risk; for example, avoiding animal bites, insect precautions, and food and water precautions. All travelers should practice these preventive behaviors, but they are critical for travelers who elect not to receive recommended vaccinations for financial reasons.

MALARIA CHEMOPROPHYLAXIS

Malaria chemoprophylaxis can also be a financial burden for the traveler. The risk of acquiring malaria in the affluent traveler staying in air-conditioned hotels and commuting in a rented car is much lower than that assumed by the young backpacker staying in a rural guesthouse or the traveler returning to his native land staying with friends or relatives. Tailoring advice to the traveler’s financial needs in addition to his or her medical needs can improve compliance with prophylaxis and protect those who are at highest risk.

Costs associated with the different regimens vary widely. For example, based on current prices in the United States, a prophylactic treatment course for a 3-week trip to a malaria-endemic destination would be $30 for doxycycline, $45 for chloroquine, $80 for mefloquine, and $150 for atovaquone-proguanil (depending on health insurance and other factors). When cost is a primary consideration, doxycycline should be considered, although accompanied by detailed instructions about how to take this medication and information about potential adverse events and how to manage them. Atovaquone-proguanil cost may be equivalent with mefloquine for short trips, but mefloquine (or chloroquine, in the few regions where malaria remains susceptible) will be more cost-effective for longer trips. Travelers who raise the option of purchasing antimalarial drugs at their destination need to be advised about the risk of inappropriate and counterfeit medications (see Perspectives: Pharmaceutical Quality & Counterfeit Drugs later in this chapter).

PREVENTIVE BEHAVIORS

Budget travelers and those who cannot afford costly travel vaccines will continue to challenge travel medicine practitioners. Travelers who cannot afford all available vaccines will appreciate additional strategies to safeguard their health during travel. These strategies include information about safety and security and general information about sun protection, food hazards, and road traffic injury. Travelers can be reassured that this information addresses hazards that are, in fact, more common than many of the vaccine-preventable diseases and that the actions they take to avoid these hazards may, in the long run, be more beneficial than obtaining vaccines for diseases of low prevalence.